Recommended Empirical Antibiotic Regimens for MICU Patients

Recommended Empirical Antibiotic Regimens for MICU Patients

Notes: The antibiotic regimens shown are general guidelines and should not replace clinical judgment. Always assess for antibiotic allergies. Antibiotic doses shown are for normal renal function - adjust for renal insufficiency as appropriate.

Indication

Source unknown Sepsis syndrome, unclear source and resuscitated (defined as SpO2 >95% with respiratory support up to FiO2 40% and PEEP 5, off pressors)

(*when source known or suspected, select empiric therapy for that source per recommendations below*)

Recommended empiric therapy

Vancomycin weight-based IV dosing plus Cefepime 2gm IV Q12H

Add metronidazole if possible intraabdominal source

Discontinue vancomycin if no MRSA identified at 48 hours

Alternative (use for mild-moderate

-lactam allergy)

No change

Severe -lactam allergy

Vancomycin weight-based IV dosing plus Aztreonam 2gm IV Q8H Add metronidazole if possible intraabdominal source Discontinue vancomycin if no MRSA identified at 48 hours

Septic shock and/or severe respiratory failure (refractory hypotension, PaO2/FiO2 ratio of >250) unclear source

(*when source known or suspected, select empiric therapy for that source per recommendations below*)

Vancomycin weight-based IV dosing plus Cefepime 2gm IV Q12H plus Levofloxacin 750mg IV Q24H OR

Amikacin 15mg/kg IV Q24H

Add metronidazole if possible intraabdominal source

No change

Discontinue vancomycin and 2nd gram-negative agent if no MRSA or resistant gram-negative organism, identified by 48 hours

Vancomycin weight-based IV dosing plus Levofloxacin 750mg IV Q24H plus Amikacin 15mg/kg IV Q24H OR

Aztreonam 2gm IV Q8H

Add metronidazole if possible intraabdominal source

Discontinue vancomycin and 2nd gram-negative agent if no MRSA or resistant gram-negative organism, respectively, identified by 48 hours

Add Micafungin 100mg IV daily and consider ID consult if persistent fever and hemodynamic instability despite broad-spectrum antibacterial therapy and one or more of the following: 1. Candida colonization of multiple sites (urine + BAL for example) 2. Total parenteral nutrition (TPN) 3. Solid organ or hematopoietic cell transplantation 4. Prior surgery, especially abdominal 5. Underlying hematologic malignancy 6. Currently undergoing chemotherapy 7. Central venous catheter

may be associated with increased risk of non-convulsive status in patients over the age of 50 with significant CNS pathology, renal failure. Consult with ICU pharmacist for optimal dosing in these patients.

Pulmonary Infections Community-acquired pneumonia (NOTE: if septic shock present, refer to the recommendations for septic shock in the previous box)

Health care-associated / hospitalacquired pneumonia

Confirmed MRSA pneumonia (blood or pleural fluid culture +, sputum with >25 PMNs, culture + and no other organisms, BAL 10,000 cfu/mL in the presence of fever, leukocytosis and pulmonary infiltrates)

Ceftriaxone 1gm IV Q24H plus Azithromycin 500mg PO/IV Q24H

No change

Consider addition of Vancomycin and ID consult if risk factors for MRSA pneumonia: necrosis/cavitation, post-influenza pneumonia or other clinical suspicion for S. aureus pneumonia

Vancomycin weight-based IV dosing plus Cefepime 2gm Q8H

No change

May consider addition of 2nd gramnegative agent (levofloxacin or amikacin)

Obtain quantitative sputum culture and stop vancomycin if MRSA not identified within 48 hours

Vancomycin weight-based IV dosing; No change

Indications for Linezolid 600mg IV every 12 hours where there is no clinical improvement with Vancomycin: Vancomycin MIC >1, severe necrosis/cavitation. Consult Infectious Disease.

Levofloxacin 750mg PO/IV Q24H* See recommendations regarding suspected MRSA in first box

Vancomycin weight-based IV dosing + Levofloxacin 750mg IV Q24H* May consider addition of 2nd gramnegative agent (aztreonam or amikacin)

No change

COPD exacerbation (without pneumonia)

Azithromycin 500mg IV x 1, then 250mg IV or PO Q24H OR

No change

No change

*fluoroquinolones have activity against Mycobacterium tuberculosis. If TB risk factors, call ID. may be associated with increased risk of non-convulsive status in patients over the age of 50 with significant CNS pathology, renal failure. Consult with ICU pharmacist for optimal dosing in these patients.

Doxycycline 100mg PO BID

Acute aspiration pneumonia

Ceftriaxone 1gm IV Q24H

Lung abscess, aspiration pneumonia Unasyn 3gm IV Q6H presenting from community

No change Clindamycin 600mg IV Q8H

Levofloxacin 750mg IV Q24 No change

Skin and soft tissue infections Cellulitis WITHOUT cutaneous abscess, low clinical suspicion for necrotizing fasciitis?

Cellulitis WITH cutaneous abscess, draining or to be drained

Vancomycin weight-based IV dosing plus Cefepime 2gm IV Q12H

Vancomycin weight-based IV dosing Plus Cefepime 2gm IV Q12H

Vancomycin weight-based IV dosing plus Levofloxacin 750mg IV Q24H

Vancomycin weight-based IV dosing No change

No change

Necrotizing fasciitis, suspected or confirmed (consult General Surgery and ID)

Diabetic foot ulcer infection

Odontogenic space infection/parapharyngeal abscess

Vancomycin weight-based IV dosing plus Piperacillin/tazobactam 4.5gm IV Q8H plus Clindamycin 900mg IV Q8H Vancomycin weight-based IV dosing plus Piperacillin/tazobactam 4.5gm IV Q8H

Unasyn 3gm IV Q6H

Vancomycin weight-based IV dosing plus Cefepime 2gm IV Q8H plus Clindamycin 900mg IV Q8H

Vancomycin weight-based IV dosing plus Cefepime 2gm IV Q8H plus Metronidazole 500mg IV Q8H Clindamycin 600mg IV Q8H

Vancomycin weight-based IV dosing plus Levofloxacin 750mg IV Q24H plus Clindamycin 900mg IV Q8H

Vancomycin weight-based IV dosing plus Levofloxacin 750mg IV Q24H plus Metronidazole 500mg IV Q8H No change

Urinary tract infections

?Cellulitis that is not the primary reason for ICU admission or is mild should be treated with Vancomycin alone, no additional gram negative coverage is necessary

Urinary tract infection from community -minimal risk for multi-drug resistant organism

Urinary tract infection from community -moderate to high risk of multi-drug resistant organism or from long-term care facility Urinary tract infection, hospitalacquired Intra-abdominal infections Spontaneous bacterial peritonitis

Upper GI bleed prophylaxis (only indicated in patients with cirrhosis) Uncomplicated intra-abdominal infection

Examples: Appendicitis without perforation Acute biliary tract infection (cholecystitis, cholangitis) Central nervous system Acute bacterial meningitis

Ceftriaxone 1gm IV Q24H

Note: agent of choice for pansusceptible E. coli is cefazolin 1gm IV Q8H Cefepime 2gm IV Q8H

Cefepime 2gm IV Q8H

Ceftriaxone 2gm IV Q24H Ceftriaxone 1gm IV Q24H

Ceftriaxone 1gm IV Q24H plus Metronidazole 500mg PO Q8H

Ceftriaxone 2gm IV Q12H plus Vancomycin weight-based IV dosing plus Ampicillin 2gm IV Q4H (if risk for Listeria)

Other clinical scenarios Febrile neutropenia

Cefepime 2gm IV Q8H

No change Note: agent of choice for pan-susceptible E. coli is Cefazolin 1gm IV Q8H No change

No change

No change No change No change

Ceftriaxone 2gm IV Q12H plus Vancomycin weight-based IV dosing plus TMP-SMX 20mg/kg/day IV divided Q6H (if risk for Listeria)

No change

Aztreonam 2g IV every 8 hours

Aztreonam 2g IV every 8 hours

Aztreonam 2g IV every 8 hours

Levofloxacin 750mg IV/PO daily Levofloxacin 750mg IV/PO daily Levofloxacin 750mg IV/PO daily Plus Metronidazole 500mg PO Q8H

Aztreonam 2g IV ever 6 hours Plus Vancomycin weight-based IV dosing plus TMP-SMX 20mg/kg/day IV divided Q6H (if risk for Listeria)

Aztreonam 2g IV every 8 hours

Add vancomycin if risk factors for MRSA infection present

Add vancomycin if risk factors for MRSA infection present

Necrotizing pancreatitis

Consider surgery (Barnett if possible) and consider GI (Attwell if possible) and ID consult (Haas) for comanagement. All three attendings would be interested in a multidisciplinary approach to management of these patients

See recommendations for sepsis and septic shock depending on clinical condition.

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download